NCBH/School of Medicine/WFBH Community Physicians EmployeeBLS/ACLS Combined Update Registration Form

NOTE:Participants must present a copy of their expiring ACLS card. In order to attend a refresher class, you must have taken ACLS within the last five years. If class taken outside Life Support Education, fax a copy of the card to 336-716-5927 with note stating which class you registered for.

Are you an NCBH, School of Medicine, or

WFBH Community Physicians Employee

*Note to ALL School of Medicine/Health Sciences and WFBH Community Physicians Employees:Please send a signed and completed authorization form to Life Support EducationBEFORE the scheduled day of class. This form must be completed by theadministrative person in your area and allows us to bill your department for the course.This is a requirement to attend class. You can find this form on theLife Support Education website under FORMS.

Date to Attend

Last Name

First Name

Middle Initial

Employee ID

Credentials (MD, RN, etc)

Phone Number

Alternate Phone Number

Department Name

Department Number

E-mail Address

Re-Enter E-Mail Address

By choosing “yes,” I understand that I must complete the ACLS precourse assessment, score at least an 80%, print the results, and bring it with me to class.

Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.